Cliff Porter Jr. [00:00:02]:

So ultimately, less Medicaid resources to a state, to a governor, impact everybody. And the reality is, you know, we then get to hand to hand combat in the state capitals around the country to preserve funding. And it creates, you know, what we affectionately say, a food fight. And that’s the last position you really want to be in because, you know, at the end of the day, all the services that are being offered are particularly through Medicaid are noble and needed.

Narrator [00:00:36]:

Welcome to Hospitals in Focus from the Federation of American Hospitals. Here’s your host, Chip Kahn.

Chip Kahn [00:00:44]:

Medicaid serves over 72 million Americans. It assures care and services for low income adults, children, pregnant women, adults with disabilities and seniors who require long term care. Healthcare and residential facilities, including hospitals, nursing homes, community health centers and many others, all serve Medicaid recipients and will be deeply impacted by the cuts included in Congress’s budget reconciliation. At the Federation, we advocate for the hospital perspective facilities that deliver a significant portion of their care to Medicaid recipients and are a cornerstone of the healthcare continuum. Another side of this continuum are long term care facilities. 38% of Medicaid funding supports care in nursing homes. Any cuts threaten the stability of the entire structure of care. To speak to the impact on long term care, I’m joined by Clifton Porter Jr.

Chip Kahn [00:01:37]:

President and CEO of the American Healthcare association and the national center for Assisted Living. His organization represents a diverse set of providers who care for our nation’s most vulnerable. Cliff, thank you so much for joining me today.

Cliff Porter Jr. [00:01:52]:

Thanks for having me, Chip.

Chip Kahn [00:01:54]:

Cliff, just to get started, I just hit my 24th anniversary here at the Federation, so I guess I’ve been a long termer. But you just got going nine months ago as CEO of the American Healthcare Association. Tell us a bit about what brought you to this great position.

Cliff Porter Jr. [00:02:15]:

Well, I’ve been at the association in a prior role for I guess 11 years now. I was formerly the senior Vice President of Government Affairs. I was responsible for all of the public policy components of our advocacy work. And then through the process of working here and our previous CEO retiring, the board thought I’d be the right person to follow him. So about nine months ago I accepted the position and ascended and I’m now serving this new capacity.

Chip Kahn [00:02:51]:

Clifton, your organization is diverse and represents all kinds of important facilities. Can you give us a sense for that diversity and how broad across the country facilities that you represent are?

Cliff Porter Jr. [00:03:06]:

No, it’s a great question. We do have a very diverse association. We represent nonprofit nursing homes as well. I think we’re often categorized as the sort of for profit nursing home association. But in reality we have more nonprofit members than the leading age affiliate or the leading age national organization has nationwide. So we have a significant number of nonprofit members within our association. We also represent ICF facilities, ICD facilities that deal with the developmentally disabled, we have around the country. We represent many pediatric nursing centers, which is a little bit different focus.

Cliff Porter Jr. [00:03:50]:

And we also represent several religiously affiliated organizations as well. We have a very significant presence of assisted living members through our national center for Assisted Living arm of our association. So we have the largest representation of assisted living facilities in the country. So we span the entire spectrum of long term care and we’re very, very happy to do that.

Chip Kahn [00:04:18]:

You know, it’s real clear that in our system we have tremendous connections across that continuum that I talked about in my introduction. Can you talk a bit about the connections between hospitals and the many diverse facilities you represent sort of on an everyday basis? You know, how does it all work?

Cliff Porter Jr. [00:04:40]:

Yeah, no, it’s another good question. I think again, I view the healthcare system very much like an ecosystem and in many ways we’re all interrelated, integrated, and in some way dependent on one another. In our case, we take care of residents, you know, Again, on a 24 hour, seven day a week basis and essentially deal with sort of comprehensive problems that those particular individuals may have relating to their activities of daily living and ability to take care of themselves. And I think that’s what would be viewed as the more traditional nursing home patient that folks think about when they think about a nursing home. But the reality is a significant number of our patients, most of our admissions, frankly, and discharges are folks that come to us for a short term period of time. They get rehabilitation and ultimately go back home. So we’re really proud of that aspect as well, because frankly, the majority of the patients that are admitted into our facilities are actually discharged back home to hopefully experience a full recovery and if not, may come back to us again for subsequent services. So the complexity is varied.

Cliff Porter Jr. [00:05:48]:

Our facilities, not, you know, not unlike hospitals, frankly in communities, have even different areas of specialty. There are facilities that have cardiac rehab specialties. There are facilities that have nephrology specialties with dialysis units on site. There are facilities that have and offer ventilator care as an example. I mentioned earlier the pediatric focus. So not unlike hospitals, nursing homes become pretty complex entities and are actually fulfilling much more niche services than they have in the past.

Chip Kahn [00:06:22]:

I just assume for our conversation today that Medicaid, across the spectrum of those facilities is a key payer, right?

Cliff Porter Jr. [00:06:34]:

Oh, gosh, yeah. It’s the foundation, frankly, of our operations. About 63% of our residents receive Medicaid. So just, you know, if you think about that, and I mean, it’s a significant number of our patients. And again, that varies depending on the geography. I would say that just like hospitals, nursing centers around the country are ultimately reflections of the community that they reside in. So if you have a facility in a more affluent suburb like Potomac, Maryland, as an example, you’re probably going to have less Medicaid. But again, if you get into more urban settings or other areas and rural settings, then it may be more Medicaid.

Cliff Porter Jr. [00:07:13]:

But on average, again, 63% of our residents are on Medicaid. And interestingly enough, one in five assisted living residents are on Medicaid through waiver programs. And obviously that’s a big concern with this bill because those are optional services the states offer. And usually when there are cuts, the optional is what is more or less reduced or eliminated first. So that is a big concern. And we have about 55,000 IDD, which is our intellectually disabled arm, the residents that we serve in intermediate care facilities. So again, all of these different service lines are totally and completely dependent on Medicaid. And in some cases, upwards of 90 to 100% of facilities are patients are on Medicaid, just depending on where they’re located.

Cliff Porter Jr. [00:08:05]:

So again, it is the foundation of all that we do.

Chip Kahn [00:08:10]:

So under financing in any form is going to be a big problem. It sounds like.

Cliff Porter Jr. [00:08:15]:

Well, it takes bad to worse. Our Medicaid system unfortunately underfunds us today. So even with 63% of our patient population being on Medicaid, we only get reimbursed on average about 82 cents on the dollar for Medicaid. So. And that includes provider taxes, mind you. So when you talk about, particularly the debate that’s currently going on, the reconciliation process around provider assessments and dialing them down, the reality is that’s less resources to the states and less resources to the states, you know, ultimately jeopardize an already underfunded system for nursing homes. So Medicaid is incredibly important, but it does underfund us and we rely on other payers to cross subsidize the losses in Medicaid to ultimately make these facilities work in the communities that they serve. So again, a real important issue you elevate.

Chip Kahn [00:09:16]:

So let’s talk specifically about this reconciliation package. And you brought up the issue of the taxes, which is where the revenue’s raised and then the other side, where it’s through State directed payments and other means is given out as supplemental payment. What’s the impact going to be from what we’ve seen in the House bill, but more importantly, I guess now in the Senate bill, which, which, which goes even deeper.

Cliff Porter Jr. [00:09:45]:

Yeah, no, I mean, we’re obviously very concerned because I’ve had an opportunity in my career to work on state level issues. And as you know, Medicaid is a state administered program and the funding that goes to facilities is directed by the state. So obviously state legislatures can determine on their own what rates are going to be. And governors, as I’ve always said, they deal with real cash. They have to have cash to pay their bills. They don’t have the luxury of being able to print money or extend debt. They have to print the cash and they have to make the numbers work. So ultimately less Medicaid resources to a state, to a governor, impact everybody.

Cliff Porter Jr. [00:10:32]:

And the reality is, you know, we then get to hand to hand combat in, in the state capitals around the country to preserve funding and it creates, you know, what we affectionately say, a food fight. And that’s the last position you really want to be in because you know, at the end of the day all the services that are being offered, particularly through Medicaid, are noble and needed. So you know, for us we have real concerns. I mean there’s lots of talks about specificity and, and this program and that program. But you know, Medicaid, you know, whether we like it or not, is an incredibly complex program that states have a variety of different levers that they use to ultimately help deliver care to the impoverished and seniors in their, in their states. And when you tinker with one, it impacts them all. And that’s the real concern.

Chip Kahn [00:11:25]:

So we’ve got to worry about this sort of domino effect. What effect is if these cuts go forward at the levels that have been talking about, will it have on specific facilities? What are the managers of your facilities going to have to do to do belt tightening or what’s the effect going to be on those that need the care or need the support if they’re living in a nursing home?

Cliff Porter Jr. [00:11:52]:

Yeah, I mean, another good issue and good question. You elevate and you know, and I may have shared this with you before. The first 15 years of my career I’ve spent running nursing homes and assisted living facilities. I’ve got some very direct experience in making all that stuff work. And a couple things have to happen. I mean one, a lot of it depends on what percentage of my facility is Medicaid. So obviously if I have A if I’m above the averages as it relates to that 63%, I’m more impacted. The struggle is always about hiring and retaining competent and qualified staff.

Cliff Porter Jr. [00:12:31]:

And one thing I didn’t talk about is just the acuity level, particularly in nursing facilities around the country, is consistently year after year gone up and the length of stay has actually gone down. So when you have, you know, an increased acuity and a decreased length of stay, you really do need highly capable staff members, registered nurses in particular, nurse practitioners, LPNs, CNAs, a variety of folks to make these assessments and assure the patients get care. When these resources are cut, we can’t necessarily compete as well in our local markets to attract that staff. And as a result, if we don’t have the staff, then I don’t care how many beds we may have available. At the end of the day, we can’t care for patients. And as a result, the capacity within the community shrinks. What happens when the capacity shrinks? That’s when the hospitals get captured, concerned, because they’re then in the position where, wait a minute, you know, Porter Nursing center, you normally are taking 10 of our discharges a week, and you’re telling me you can’t now because you, you don’t have any beds? Well, I heard you had 20 beds. Well, you know, the reality is I don’t have the staff.

Cliff Porter Jr. [00:13:43]:

So now those patients are staying in your hospital and, you know, preventing patients that need other services from getting them, and it essentially clogs the entire ecosystem. So this is, as you said, a domino effect situation that we have to be very, very, very concerned about.

Chip Kahn [00:14:02]:

Yeah, I’m worried too, and I sort of ask you about this. Obviously, there are physicians, there are other caregivers that you have to have come into your facilities to provide services. Frequently they’ll be independent of the facility. And if the cuts are great enough, it’ll cause a great deal of problems for you to get the kind of outside services that you all depend on for your patients.

Cliff Porter Jr. [00:14:32]:

There’s no question. And again, the healthcare system is an ecosystem, and what impacts one, impacts everyone. And the reality that you put forth is that, you know, at the end of the day, we need competent people, experts caring for our seniors because they have more complex conditions than what they’ve traditionally had in the past. You know, when I started the business 35 years ago, really, you know, nursing homes were full of, full of people that are now in assisted living facilities, in some cases even independent living facilities. For that matter, the folks that we’re caring for are Significantly more compromised. They have more issues, more medications, and require a much more complex approach to caring for them. So, again, it puts a demand upon a higher caliber of staff that we all need. And this population in particular is exploding.

Cliff Porter Jr. [00:15:28]:

I talk about it often in our speeches that I do around the country. Between now and 2030, there will be 4 million more people over the age of 80. Between 2030 and 2035, there will be another 4 million over 80. Between 2035 and 2040, another 4 million over 80. So in the next 15 years, we’ve got effectively 12 million more people over the age of eighty. And we know in hospital services and nursing home services, that’s when things just start to break. We can run, we can exercise, we can do all the things that we can. But you get to a certain age and stuff just starts to expire.

Cliff Porter Jr. [00:16:04]:

And when that happens, you need health care, and so you need hospital care, you need nursing health care, you need rehabilitative services. So we have this exploding population, and yet we’re talking about reducing, reducing resources to care for them. And I think that’s just uninformed.

Chip Kahn [00:16:21]:

I want to ask a bit about the. Another aspect of the bill, but before I go there, in terms of these cuts, what’s your message to Capitol Hill here as it takes up this legislation?

Cliff Porter Jr. [00:16:34]:

Well, I think the main message is this, and I believe we’re making some progress. There is an understanding that Medicaid underfunds nursing home care. And there was an attempt in the most recent Senate bill to actually more or less insulate nursing facilities and ICD facilities from any reductions to provider taxes. So while that is appreciated, and it really is, because we did a lot of work to make sure that they understood that, you know, again, you’re making a bad situation worse by reducing that particular, particular benefit, that’s a positive, and we’re encouraged by that, that there’s some understanding. But again, gets back to the broader discussion. Again, you know, I had a conversation with some of my friends in Ohio, and, you know, their big concern is the hospital provider tax. And the reality is the way the arrangement is established, that some of those resources, even from the hospital provider tax, are distributed, redistributed across, across the entire Medicaid system. So indirectly, part of the Ohio reimbursement to nursing homes is dependent upon the hospitals getting their provider assessment money.

Cliff Porter Jr. [00:17:50]:

So, you know, again, I think that what we’re attempting to do is to just tell that story and to articulate the complexity and to keep hammering the point about consequences. And more importantly, Making sure that we’re making an informed decision. Decision. I think no one disagrees. I know, I don’t that provider taxes, provider assessments, state directed payments are complicated programs that are, you know, tough to even understand. But we can’t say we’re going to do away with something without offering an effective alternative that ensures the resources get to where they’re designed to go. And right now what we’re saying is we’re just kind of going to eliminate a program which is effectively a cut versus saying, okay, well maybe we don’t like the way this is structured and we want to rethink how we do this and here is an alternative to that, then we can, you know, I think have a much more constructive discussion. But, you know, as it stands, obviously we’re just very concerned that there’s not as much of appreciation as it relates to the magnitude and the complexity of Medicaid writ large and how any changes impact everyone.

Chip Kahn [00:19:02]:

Well, I appreciate, I appreciate that message, Clifton. Hopefully they’ll get the message and get the memo on Capitol Hill. One aspect of the bill, though, does address this issue in, in the case of nursing homes, of a mandate, a nursing mandate. Can you talk a bit about the workforce issues that you face? And I, I, I think you’ve got some other information about it that could be helpful for our audience.

Cliff Porter Jr. [00:19:28]:

Well, yeah, I’m glad you brought that up. It’s a really important component of the reconciliation bill and one that we fully support. So again, we are appreciative that we’ve gotten an understanding clearly that creating a staffing mandate in an environment where there aren’t enough staff is not going to work and needs to be stopped. And the good news is we did have two recently, a second court decision that invalidated the CMS rule that President Biden put forth during the Biden administration to essentially force higher staffing levels in nursing centers. And again, we support and agree that additional staff would benefit quality, but the reality is the staff aren’t there. So the court decisions essentially, particularly the one in Texas, invalidated that rule. And then we compound that with now the statute actually being changed that completely, effectively outlaws, for lack of a better term, a mandate for staffing. So that, that’s a very good thing.

Cliff Porter Jr. [00:20:43]:

Again, when I talk about the statistical data, the demographic data, I talked about the 4 million people. Another important statistic is that today, 8.29, there are 8.29, 18 to 45 year olds for every 80 year old and 18 to 45 is an important cohort because those are the Folks that can lift people, change people, provide the kinds of hands on care effectively. If you fast forward 20 years from now, that number drops to four, half four people for every 80 year old. So and obviously that’s a combination of this explosion of demand and frankly supply not growing and increasing sufficiently to keep up. So we’ve got real demographic issues in our country that are beyond, you know, just a staffing mandate is a solution. We’ve got to do a comprehensive and take a very comprehensive approach to addressing the caregiver challenge of the future because we’ve got technology, we’ve got AI, and I believe that will all have an impact on healthcare. But at the end of the day, if I’m 85 years old, I’m going to need a person to ultimately feed me if I need to be fed or bathe me if I need to be bathed. And that can’t be replaced necessarily by technology.

Cliff Porter Jr. [00:22:06]:

Or maybe I don’t want it replaced by technology. That might be a better way to say it. But again, we need human beings and at the end of the day we are in a situation where demographically we have real challenges in our country and if we don’t get smart about it and get on it pretty quickly, I think we’re going to be overwhelmed.

Chip Kahn [00:22:25]:

Today you feel confident that in terms of protecting the patients, protecting the residents, that you’re doing the job and that this was really burdensome, this mandate that was envisioned in the regulation.

Cliff Porter Jr. [00:22:39]:

Yeah, the law is clear and I think that was really the basis of the case. And the law requires at least eight hours of registered nurse coverage a day. And there is academic data that proves that the more registered nurse present, the better the quality. And we agree with that, we fundamentally agree with that. But the reality for us is that the registered nurses don’t exist. And you know, again, we’ve got to think about, again, how do we put the horse before the cart, not the cart before the horse. So would we like to have more registered nurses? Absolutely we would. Do we work hard every day to accomplish that? Absolutely we do.

Cliff Porter Jr. [00:23:21]:

But the reality is that we got a bigger problem that a mandate simply won’t solve. So I’m hopeful, particularly after we get reconciliation behind us, that you and me and the entire healthcare community can actually work together to really ring the bell and sound the alarm that, look, we got to get serious about this and we got to really begin to think about supply of caregivers in our country and work hard at forcing the government to really make some investments to help us accomplish that. Because if we don’t, the entire system will seize in my view.

Chip Kahn [00:23:55]:

Well Cliff, I really appreciate you joining me today and appreciate your message and appreciate your commitment and service to such an important part of healthcare delivery and supporting our most vulnerable in our society and our communities across the country. And glad to collaborate and continue our collaboration and look forward to working with you into the future.

Cliff Porter Jr. [00:24:22]:

Chip, I appreciate the time and I appreciate your listeners and obviously we’re all in this together and I think we just have to continue to join forces and coordinate our messaging and hopefully we can get through this situation successfully and more importantly build a better future for all these folks that are going to need our services. So again, looking forward to working with you and appreciate the opportunity.

Chip Kahn [00:24:43]:

Great Cliff, this was great and I just appreciate you participating today in our conversation on Hospitals and Focus. The reality is simple. Patients rely on connected, coordinated systems of care. Hospitals can’t do it alone. Neither can long term care providers. Medicaid cuts that destabilize one part of the system inevitably affect all the rest. Policymakers must recognize that that preserving access to care means protecting the full spectrum of care from primary care to hospitals to post acute to long term care. Hopefully they’ll listen to our strong voices on protecting patients and protecting those in Medicaid.

Narrator [00:25:36]:

Thanks for listening to Hospitals in Focus from the Federation of American Hospitals. Learn more at fah.org. Follow the federation on social media @FAHHospitals and follow Chip @ChipKahn. Please rate, review and subscribe to Hospitals in Focus. Join us next time for more in depth conversations with healthcare leaders.

Clifton (Clif) Porter is the President & CEO at AHCA/NCAL.  Porter has been serving the needs of seniors in the long term care field for over 30 years, beginning his career as an administrator in training at a skilled nursing facility in 1989, serving as an administrator of several skilled nursing centers from 1990 through 1998, and capping his operational experience as a regional director of operations for a large-urban market from 1998 through 2004. Porter then accepted the challenge of leading HCR ManorCare’s Government Relations Department from 2004 to 2013 as its Vice President of Government Relations and served on various state healthcare association boards from 2004 to 2013. 

Today, Porter leads AHCA/NCAL’s national advocacy efforts, championing policies that protect high-quality care and strengthen the long-term care workforce. With his experience, he understands the devastating impacts that Medicaid cuts would have on residents and providers and is determined to ensure critical funding is preserved.  

Porter holds a Bachelor of Science degree from the Virginia Commonwealth University School of Medicine in Healthcare Management. You can learn more about the devastating impacts Medicaid cuts will have on nursing homes from our provider survey: www.ahcancal.org/providersurvey 

To learn more about AHCA/NCAL’s advocacy efforts visit www.ahcancal.org. You can also find us at: Facebook, X, LinkedIn and YouTube.